Provider Demographics
NPI:1023622461
Name:SHAFFER, GRANT
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:SHAFFER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 JAMES RD UNIT 1D
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27265-2397
Mailing Address - Country:US
Mailing Address - Phone:410-960-5642
Mailing Address - Fax:
Practice Address - Street 1:610 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WALNUT COVE
Practice Address - State:NC
Practice Address - Zip Code:27052-9248
Practice Address - Country:US
Practice Address - Phone:336-591-4351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-02
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC29939183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist